Social determinants of health disparities in Staten Island compared with Manhattan, Queens, Brooklyn, and the Bronx: Contribution to COVID‐19 outcomes

Abstract Introduction Social determinants of health (SDH) negatively affected Coronavirus disease‐2019 (COVID‐19) outcomes within the five boroughs of New York City. The goal of this study was to determine whether differences in social demographics within the borough of Staten Island, compared with the other four boroughs, may have contributed to poor COVID‐19 outcomes in Staten Island. Methods Data were obtained from public data sources. Social demographics obtained included age, household income, poverty status, and education level. COVID‐19 infection, hospitalization, and death rates reported from Staten Island were compared with rates from Manhattan, Queens, Brooklyn, and the Bronx (February 29, 2020–October 31, 2022). Mean differences in case rates of COVID‐19 were higher in Staten Island compared to all four boroughs. Results Mean differences in hospitalization and death rates were higher than Manhattan but similar to the other four boroughs. Within Staten Island, case rates were highest in zip codes 10306 and 10309. Hospitalization and death rates were highest in Staten Island zip code 10304. We found that the zip codes of Staten Island with poorer COVID‐19 outcomes had more individuals with less than a high school degree, lower mean household income, higher proportion of households earning less than $25,000 a year, and a greater proportion of individuals using public transportation. Conclusion Differences in COVID‐19 infection, hospitalization, and death rates exist between the five boroughs and between the 12 zip codes within Staten Island. These differences in COVID‐19 outcomes can be attributed to different SDH.

Coronavirus disease-2019 (COVID- 19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported in Wuhan, China, in December 2019. 1 The World Health Organization (WHO) declared a Public Health Emergency of International Concern (PHEIC) on January 30, 2020 and later declared a pandemic (March 11, 2020). 2 The first case of COVID-19 in the United States was confirmed in Snohomish County, Washington (January 20, 2020). 3The first confirmed case was reported in New York City (NYC) on February 29, 2020. 4As numbers of COVID-19 cases increased, NYC became an epicenter of disease, with cases reported in all five boroughs: the Bronx, Brooklyn, Manhattan, Queens, and Staten Island. 5ach borough has a unique set of demographic and socioeconomic characteristics, with variation between different neighborhoods within a borough.Initial studies from 2020 reported COVID-19 case rates, hospitalizations rates, and death rates varied significantly across the five boroughs. 6,7The differences in COVID-19 reporting within the five boroughs may be attributable to the social determinants of health (SDHs).The SDHs are defined as conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of liferisks and outcomes including but not limited to socioeconomic class and political and cultural factors. 8f notable interest, Staten Island, considered a relatively affluent borough, 9 was a hotspot for COVID-19 disease as of April 13, 2020 9 ; the highest average case counts were reported in Staten Island (1578-2258/100,000) compared with the other boroughs (Manhattan, Queens, the Bronx and Brooklyn) (553-962/10,000; 1242-1726/100,000; 1462-2042/100,000; 902-1254/100,000, respectively). 10Staten Island also was the only borough that reported case rates higher than 1380/100,000 within each zip code, whereas the other boroughs had zip codes with case rates as low as 300/100,000. 10Public online data reported SDHs and COVID-19 outcomes in NYC; however, it remains unclear whether SDHs constitute a causative relationship with COVID-19 outcomes within the different boroughs.Staten Island ranked higher than the other boroughs regarding different SDH factors (e.g., education level, poverty status, household income). 9However, those factors may not have been equally distributed among the different neighborhoods/zip codes within Staten Island.
To address this knowledge gap, we evaluated whether distributions of SDHs-education level, poverty status, household income, mode of transportation-affected numbers of COVID-19 cases, hospitalization rates, and death rates in individual neighborhoods (e.g., zip codes) of Staten Island compared with the other boroughs (March 2020-October 2022).In addition, we sought to determine whether differences in social disparities exist within one borough, (e.g., Staten Island and the other boroughs).These differences may have played a distinct role for the higher number of case rates reported in Staten Island.

| METHODS
This was a retrospective study.Social and clinical demographic characteristics were obtained from a nationwide cohort design including all individuals residing in Staten Island, Manhattan, Queens, the Bronx, and Brooklyn, using public city-wide registries. 11,12nclusion criteria included SARS-CoV-2 infections, hospitalization rates, and death rates, due to SARS-CoV-2, between February 29, 2020 and October 31, 2022. 12orough-wide social demographics of interest were collected from the 2019 American Community Survey (ACS) profile report 11 and the United States Postal Service, US Census Bureau and included age, sex, race, household income, poverty status, and education level. 13ach neighborhood was defined by a residential area corresponding to a zip code.No individual-level data were involved in the analysis.The ACS is a source of information about America's changing population; ACS data are collected primarily over the internet through self-administered questionnaire.The data from this study was obtained from online public databases and was exempt from IRB approval.Hospitalized was defined as taking someone to the hospital and keeping them there for treatment.Fatality was defined as an occurrence of death due to war, accident or disease.

| RESULTS
The most cases reported were in zip codes 10306 and 10309 (383 ± 573, 373 ± 550, respectively), in the New Dorp (10306) and Prince's Bay (10309) neighborhoods (Table 5). 14These two zip codes are located in the central and southern sections of Staten Island, respectively (Figure 1).Mean differences in case rates were compared between zip code 10306 and the other zip codes in Staten Island and were found to be higher (p < .05),except in zip code 10309 (p = .21)(Wilcoxon test) (Table 6).Mean differences in case rates were compared between zip code 10309 and the other zip codes in Staten Island and were found to be higher (p < .05),except in zip code 10306 (p = .21)and in zip code 10312 (p = .21)(Wilcoxontest) (Table S1).Zip code 10312 is located in the southern section of Staten Island, between zip codes 10306 and 10309 (Figure 1).
The most hospitalizations reported were in zip code 10304 (85 ± 87), in the Stapleton neighborhood (Table 5). 14This zip code is located in the northeastern section of Staten Island (Figure 1).Mean differences in hospitalization rates were compared between zip code 10304 and the other zip codes in Staten Island and were found to be higher (p < .05)except in zip codes 10301 (5 ± 28, p = .14),10302 F I G U R E 2 Mean hospitalization rates per 100,000 people in the different Staten Island zip codes (2020-2022).The three zip codes with the highest hospitalization rates are colored red and the three with the lowest hospitalization rates are colored green.Zip codes are written in bold letters.Rates are located below the zip code.Source: New York State Department of Health, accessed December 22, 2022. 143 ± 24, p = .46),and 10306 (6 ± 37, p = .47)(Wilcoxon test) (Table S2).Zip codes 10301 and 10302 are located in the northern section of Staten Island while 10306 is located in the central section of Staten Island (Figure 2).
The three zip codes with the highest case rates (10306, 10309, and 10312) were located in the southern area of Staten Island (Figure 1).The three zip codes with the lowest case rates (10301, 10304, and 10314) were located in the central area of Staten Island (Figure 1).
The three zip codes with the highest hospitalization rates (10301, 10302, and 10304) were located in the northern area of Staten Island (Figure 2).The three zip codes with the lowest hospitalization rates (10307, 10308, and 10309) were located in the southern area of Staten Island (Figure 2).Trends showed that these three zip codes were those with the highest proportion of households with an annual income greater than $150,000 (23,281 per F I G U R E 3 Mean death rates per 100,000 people in the different Staten Island zip codes (2020-2022).The three zip codes with the highest death rates are colored red and the three with the lowest death rates are colored green.Zip codes are written in bold letters.Rates are located below the zip code.Source: New York State Department of Health, accessed December 22, 2022. 1400,000; 22,620 per 100,000; 22,992 per 100,000; respectively) and the highest proportion of White, Non-Hispanic inhabitants (93,431 per 100,000; 93,592 per 100,000; 91,058 per 100,000; respectively) (Table S4).
The three zip codes with the highest death rates (10301, 10304, and 10306) were located in the northern and central area of Staten Island (Figure 3).The three zip codes with the lowest death rates (10301, 10304, and 10306) were located in the southern area of Staten Island (Figure 3).Trends showed that these three zip codes were those with the highest mean household incomes ($102,903; $93,266; and $87,692; respectively), the lowest Note: Data collected from the United States Postal Service, US Census Bureau. 13mber of individuals with education levels less than high school (5576 per 100,000; 6000 per 100,000; 6124 per 100,000; respectively) (Table S4).

| DISCUSSION
This analysis found that case rates of COVID-19 were higher in Staten Island compared with the other four boroughs.However, hospitalization rates and death rates in Staten Island were not higher compared with Brooklyn, the Bronx, and Queens.Even though case rates were higher in Staten Island, clinical outcomes were not as high as expected.This could be attributed to more favorable social determinants of health within the population of Staten Island.Within specific zip codes (10307, 10308, 10309, and 10312) of Staten Island, hospitalization and death rates were lower depending on presence of protective SDH (lower proportion of individuals with less than a high school degree, higher mean household income, higher proportion of households with an annual income greater than $150,000).The distribution of COVID-19 outcomes, including number of cases, deaths, hospitalizations, tests, and vaccinations across the five boroughs can provide insight into the factors influencing COVID-19 statistics in different neighborhoods.Prior studies reported variations in COVID-19 statistics between the boroughs attributable to the SDHs, suggesting communities with negative SDHs were disproportionally affected by COVID-19. 6,9,10,15,16oten et al. compared the Social Vulnerability Index (SVI), a metric created by the CDC tracking 15 social factors observed to affect health, 17 of each NYC county-Kings county, Queens county, New York county, Bronx county, and Richmond county-in regard to COVID-19 cases, deaths, and hospitalizations in March 2020 and May 2020. 9Based on the reported SVI, counties were designated low, moderate, or high vulnerability (LV, MV, and HV) with results showing that the average numbers of daily COVID-19 cases and deaths in the MV and HV counties were greater than those of the LV counties. 9Additionally, Wadhera et al. compared the rates of hospitalizations and deaths within each borough up to April 25, 2020 to demographic characteristics such as race, poverty status, and education level. 6The findings showed that the most affluent borough, Manhattan, experienced the lowest number of COVID-19-related hospitalizations and deaths, whereas the Bronx, which has the highest proportion of racial minorities, the most individuals living in poverty, and the lowest education level, had higher rates of COVID-19 hospitalizations and deaths. 6Predictors for COVID-19 case and death rates include proportion of residents over the age of 65, proportion of White residents, and proportion of residents without health insurance. 15f particular interest, Staten Island, considered a relatively affluent neighborhood with an SVI index of LV, 9 has been shown to be a hotspot of disease. 10Maroko et al. evaluated rates of COVID-19 case rates among the neighborhoods of NYC in comparison to poverty status, race, education level, insurance status, and median household income, finding that Staten Island, despite having a relatively higher proportion of white residents, a relatively higher median household income, and relatively lower unemployment rate, had case rates similar to neighborhoods of the Bronx and Queens with a higher proportion of negative SDHs. 10 While De Jesus et al. found a number of SDHs predictive of COVID-19 cases and hospitalizations within Brooklyn, Queens, Manhattan, and the Bronx, no such explanatory variable was identified within Staten Island among 17 SDHs. 15Instead, the authors proposed that other factors unique to Staten Island predicted rates of COVID-19 cases and hospitalizations. 15his study aimed to address this knowledge gap, suggesting that it is factors within individual neighborhoods/zip codes, not Staten Island as a whole, that contribute to the high case rates.First, we evaluated the COVID-19 case rates of each borough individually to determine if Staten Island continued to be a hotspot of disease through the start of the pandemic to October 31, 2022, as previously published research evaluated statistics confined to 2020. 9,10,15We found that the mean difference in case rates was statistically higher in Staten Island as compared to the other boroughs.Similar analysis of hospitalization and death rates demonstrated that Staten Island had a statistically higher mean difference in hospitalization and death rates than Manhattan but similar numbers to the Bronx, Brooklyn, and Queens.We propose that the high case rate can be attributed to higher testing rates and testing capabilities provided by a borough with a LV index.Similarly, we propose that the hospitalization rates and death rates were similar to those rates in Manhattan as both are categorized as LV whereas the Bronx, Brooklyn, and Queens are HV boroughs with less access to healthcare resources.

Borough
Analysis of different zip codes within Staten Island found that zip codes 10306 (New Dorp) and 10309 (Prince's Bay) had the highest case rates of COVID-19 whereas zip code 10304 (Stapleton) had the highest hospitalization rates and death rates. 14Protective factors decreasing hospitalization rates include a higher proportion of households with an annual income greater than $150,000 and a higher proportion of White, Non-Hispanic inhabitants.Protective factors decreasing death rates include a higher mean household income and a lower proportion of individuals with education levels less than high school.Geographically, the southern area of Staten Island had better COVID-19 outcomes, suggesting that people living in those zip codes may be realtively more affluent.
This study has limitations including differences in access to COVID-19 testing, potentially unreported cases, hospitalizations, and deaths due to SARS-CoV-2 and differences in demographics between data collection in 2019 and COVID-19 measurements 2020-2022.Also, it should be noted that during different time periods, alpha, delta, and/or omicron became the most dominant SARS-CoV-2 variant.Other concerns may include circulation of other strains and possible coinfection with other viruses.In addition, there is no individual level data available for us to include in this study.The study is mainly descriptive and may contain potential bias.
The data presented in this study contribute to our understanding of possible disparities during the COVID-19 pandemic by providing insights into the relationship between distributions of SDH and COVID-19 outcomes in Staten Island compared with the other boroughs.While Staten Island is one of the more affluent boroughs with more favorable SDH, we identified areas of interest for better targeting COVID-19 poor outcomes and underlying risk factors.Different zip codes within Staten Island demonstrated higher case rates, most probably due to the different variations of SDH exposure to disinformation about the disease in Staten Island. 18Higher ethnic variability, access to quality medical care, life style, and comorbidities are possible factors in variability in COVID-19 outcomes within each borough. 19uture planning for similar pandemics should prepare for interventions targeting the most vulnerable populations and neighborhoods within each borough.
Social demographics/social determinants of health of the five New York City boroughs as well as city-wide demographics.
T A B L E 1 T A B L E 2 Social demographics/social determinants of health of the 12 Staten Island zip codes.
16se rates, hospitalization rates, and death rates due to COVID-19 in Staten Island compared with the other four boroughs of New York City and city wide.Case rates, hospitalization rates, and death rates according to different Staten Island zip codes.higherproportions of COVID-19 cases, hospitalizations, and deaths.16DeJesus et al. demonstrated that the SDHs can predict COVID-19 case and death rates within the five boroughs through July 2021.
T A B L E 4Note: Data represented as mean differences + standard deviation (SD).A p-value of <.05 was considered statistically significant (Wilcoxon test).
10,15,16or T A B L E 6 Comparison of case rates between zip code 10306 and other zip codes in Staten Island.Data represented as mean differences + standard deviation (SD)/ 100,000 people (2020-2022).A p-value of <.05 was considered statistically significant (Wilcoxon test). Note: